3. Case Definitions
Suspected Case-
defined as a person with acute febrile
respiratory illness (fever≥38ºC) with onset:
Within 7 days of close contact with a person who
is a confirmed case of swine influenza(H1N1)
virus infection,or
Within 7 days of travel to community where there
are one or more confirmed swine influenza
A(H1N1) cases,or
Resides in a community where there are one or
more confirmed swine influenza cases
4. Probable Case-
defined as a person with an acute febrile respiratory
illness who:
► Is positive for influenza A, but unsubtypable for H1 and
H3 by influenza RT-PCR or reagents used to detect
seasonal influenza virus infection,or
► Is positive for influenza A by an influenza rapid test or an
influenza immunoflourescence assay(IFA) plus meet
criteria for a suspected case.
► Individual with clinically compatible illness who died of an
unexplained acute respiratory illness who is considered
to be epidemiologically linked to a probable or confirmed
case
5. Confirmed Case:
defined as a person with an acute febrile illness
with laboratory confirmed swine influenza
A(H1N1) virus infection at WHO approved
laboratories by one or more of the following
tests:
Real time PCR
Viral culture
Four-fold rise in swine influenza A (H1N1)
virus specific neutralising antibodies
6. Close Contact:
defined as within 6 feet of an ill person who is a
confirmed or suspected case of swine influenza
A(H1N1) virus infection.
Acute Respiratory Illness:
defined as recent onset of at least two of the
following:
-rhinorrhoea or nasal congestion
-sore throat
-cough(with or without fever or feverishness)
7. Ordinary flu and pandemic flu – the
differences
Pandemic Flu Ordinary Flu
Occurs during any season Occurs every yr during winter
Affects almost half of the Affects 10-15% of world
population population,
Is a more serious infection Most recover in 1-2 wks without
treatment
Vaccine not available(new strain) Virus identified & vaccine available
in advance(protective)
People of all ages at risk of
infection
Antiviral med.stockpiled to treat
people
9. Symptoms & Signs in Swine
In pigs influenza infection produces
fever, lethargy, sneezing, coughing
, difficulty breathing and decreased
appetite.
In some cases the infection can
cause abortion.
Although mortality is usually low,
the virus can produce weight loss
and poor growth
Infected pigs can loose up to 12
pounds of body weight over a
3 to 4 week period
10. Signs and symptoms
Symptoms of novel H1N1 flu in
people are similar to those
associated with seasonal flu.
Fever
Cough
Sore throat
Runny or stuffy nose
Body aches
Headache
Chills
Fatigue
In addition, vomiting(25%) and
diarrhea (25%) have been
reported. (Higher rate than for
seasonal flu.)
12. Watch for Emergency Warning Signs
Most people should be able to recover at home, but watch for
emergency warning signs that mean you should seek immediate
medical care.
In adults:
Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Sudden dizziness
Confusion
Severe or persistent vomiting
Flu-like symptoms improve but then
return
with fever and worse cough
13. Emergency warning signs in children
If a child gets sick and experiences any of these warning signs, seek
emergency medical care.
In children:
Fast breathing or trouble breathing
Bluish or gray skin color
Not drinking enough fluids
Severe or persistent vomiting
Not waking up or not interacting
Irritable, the child does not want to be held
Flu-like symptoms improve but then return
with fever and worse cough
14. Transmission
Transmission between pigs
The main route of transmission is through direct contact
between infected and uninfected animals.
These close contacts are particularly common during
animal transport.
The direct transfer of the virus probably occurs either by
pigs touching noses, or through dried mucus.
Airborne transmission through the aerosols produced by
pigs coughing or sneezing are also an important means
of infection.
15. Transmission to humans
Through contact with infected pigs or
environments contaminated with swine flu
viruses(zoonosis)
Through contact with a person with swine flu
16. How does novel H1N1 Influenza
spread?
This virus is thought to spread
the same way seasonal flu
spreads
Primarily through respiratory
droplets
Coughing
Sneezing
Touching respiratory
droplets on yourself,
another person, or an
object, then touching
mucus membranes (e.g.,
mouth, nose, eyes)
without washing hands
17. Can you get novel H1N1 Influenza from
eating pork?
No. The novel H1N1 influenza virus
(formerly referred to as swine flu) virus is
not spread by food.
You cannot get novel H1N1 flu from
eating pork or pork products. Eating
properly handled and cooked pork
products is safe
18. High Risk Groups
Children younger than 5 years old. (more in <2 yrs old)
Adults 65 years of age and older.
Persons with the following conditions:
Chronic pulmonary (including asthma), cardiovascular
(except hypertension), renal, hepatic, hematological
(including sickle cell disease), neurologic,
neuromuscular, or metabolic disorders (including
diabetes mellitus);
Immunosuppression, including that caused by
medications or by HIV;
Pregnant women
Persons younger than 19 years of age who are receiving
long-term aspirin therapy
Residents of nursing homes and other chronic-care
facilities.
22. Cause of Death
The most common cause of death is
Respiratory Failure
Other causes-
-Pneumonia(leading to sepsis)
-High fever
-Dehydration
Fatalities are more likely in young children
and the elderly
24. INFLUENZA
What is Influenza(also called Flu)?
The flu is a contagious respiratory
illness caused by influenza viruses.It can
cause mild to severe illness, and at times
can cause death.
25. What is an epidemic, an endemic and a
pandemic?
An epidemic is a sudden outbreak of
disease that spreads through a single
population or region in a short amount of
time.
An endemic is when in a population
infection is maintained without the need for
external inputs.
26. A pandemic occurs when there is a
rapidly-spreading epidemic of a
disease that affects most
countries and regions of the
world.
27. History
Greek physician Hippocrates“ Father of
medicine” first described influenza in 412 BC
The first Influenza pandemic was recorded in
1580 and since then influenza pandemics
occurred every 10-30 years
Influenza pandemics occurred in 1729-
1730,1732-1733,1781-1782,1830,1833-
1834,1847-1848.
32. Inter epidemic phase
Phase 1 : No new subtype
human infection may be present
in animals
Phase 2 : No new subtype
circulating animal infection
33. Pandemic alert period
Phase 3 : Human infection with a new
subtype.
No human to human spread
Phase 4 : Small clusters with limited human
to human transmission.
34. Pandemic phase
Phase 5 : large clusters with human to
human transmission.
Phase 6: Increased & sustained
transmision with spread to
different continents.
36. Novel H1N1 Influenza
First identified in april 2009
Mutation of 4 known strains of influenza
virus
Outbreak began in Mexico
Transmission is human to human
Not transmitted by eating foods
38. Agent- genetic sequencing shows a new
subtype of influenza A(H1N1) virus with
segments from four influenza viruses:
-North American Swine
-North American Avian
-Human Influenza
-Eurasian Swine
39. Host factors- otherwise healthy young
adults
Transmission- Droplet infection and
fomites
Incubation Period - 1-7 days
Communicability- From day 1 before to 7
days after the onset of symptoms.
40. CDC expects that more cases, more hospitalizations, and
more deaths from this outbreak will occur over the coming
days and months.
Influenza is always serious – each year in the United
States, seasonal influenza results, on average, in an
estimated 36,000 deaths and more than 200,000
hospitalizations from flu-related causes.
This outbreak certainly poses the potential to be at least as
serious as seasonal flu, if not more so, especially given the
fact that there currently is no vaccine against this virus.
Because this is a new virus, most people will not have
immunity to it, and illness may be more severe and
widespread as a result.
43. WHO Update
Last WHO update on july 6 ,2009
94,512 confirmed cases
122 countries
429 deaths
In U.S. as of july 17,2009
40,617 confirmed cases
263 deaths
44. Indian scenario until Monday
Total 1707 cases reported
New cases 152
Cured 694
230 positive cases in Pune
Total no.of deaths so far 24
48. Antigenic Variation
Unique Feature: HA, NA undergo
independent antigenic variation
Antigenic Drift
Antigenic Shift
Drift: gradual sequential change in
antigenic structure, occurring regularly
at freq. intervals.New ags though diff.
from the prev. ags are yet related to
them-cause periodical epidemics.
49. Shift: Abrupt, drastic, discontinuous variation
in the antigenic structure resulting in a novel
virus strain unrelated antigenically to
predecessor strains-may involve both HA and
NA.
Antibodies to predecessor viruses do not
neutralise the new variants, therefore spread
widely in the popn causing major epidemics
or pandemics.
Present strain influenza 2009 A/ H1N1 is a
rare recombination of gene segments from
swine with avian and human influenza
strains.
51. Laboratory diagnosis
Demo of the virus antigen
• Direct detection
Microscopy
Ag detection
Nucleic Acid analysis
Nucleic Acid Act. Assay
Isolation
• Culture
Serological test
55. Principles of Management
1. Prevention of spread of disease from
patient to others,
2. Prompt treatment to prevent severe
illness and death,
3. Early identification and follow up of
suspected cases.
56. Infra structure/ Man power/ Material support
1. Isolation ward - Well ventilated
- Beds one meter apart
2. Man Power - Dedicated doctors
- Nurses
- Paramedical staff
1. Equipments - Portable X-Ray machine
- Oxygen
- Pulse Oxymeter
- Ventilator
1. Material - PPE, disinfectants, medicines
57. Standard Operating Procedures
1. Standard infection control precautions – PPE for all contacts
High efficiency mask Three layer surgical mask
N- 95 mask
Gowns
Goggles
Gloves
Caps
Shoe cover
2. Restrict number of visitors
3. Antiviral treatment and prophylaxis
4. Proper waste disposal
58. Anti Viral Treatment
Oseltamivir (Tamiflu)
Recommended by WHO
For treatment and prophylaxis
Adult dose -75 mg. BD
Supervised govt. supply
Other drug – Zanamivir (Relenza)
59. Doses Of Oseltamivir
By Weight:
For weight <15kg 30 mg BD for 5 days
15-23kg 45 mg BD for 5 days
24-<40kg 60 mg BD for 5 days
> 40kg 75 mg BD for 5 days
For infants:
< 3 months 12 mg BD for 5 days
3-5 months 20 mg BD for 5 days
6-11 months 25 mg BD for 5 days
It is also available as syrup (12mg per ml )
If needed dose & duration can be modified as per clinical condition.
60. Chemoprophylaxis
All close contacts of suspected , probable and
confirmed cases. Close contacts include
household/social contact , family members , work
place or school contacts, fellow travelers etc.
All health care personnel coming in contact with
suspected , probable or confirmed case.
Drug recommended - Oseltamivir
Mass chemoprophylaxis
61. Doses of Oseltamivir for chemoprophylaxis
Prophylaxis should be provided till 10 days after last exposure (maximum period
of 6 weeks)
By Weight:
For weight <15kg 30 mg OD
15-23kg 45 mg OD
24-<40kg 60 mg OD
>40kg 75 mg OD
For infants:
< 3 months not recommended unless situation judged critical due to limited
data on use in this age group
3-5 months 20 mg OD
6-11 months 25 mg OD
62. Side Effects of Oseltamivir
Generally well tolerated
Mild - Nausea , vomiting , pain in abdomen
- Vertigo , insomnia
- Bronchitis , epistaxis
Less common - Angina
- Pseudomembranous colitis
- Peritonsillar abscess
Rare - Anaphylaxis
Pregnancy - Risk benefit analysis
63. Supportive
Plenty of oral fluids
I . V. fluids
Parenteral nutrition
Oxygen
Antibiotics for secondary bacterial infection
Steam inhalation
Paracetamol / ibuprofen
Vasopressors for shock
Mechanical ventilation
66. Indication of Mechanical Ventilation
Severe pneumonia
Acute respiratory failure
SpO2 < 90% with oxygen
PaO2 < 60mm Hg with oxygen
Invasive ventilator – Preferred
Hepafilters on expiratory ports
Prophylactic antibiotic
67. Admission Policy
Severe - Admission
Mild - Option of hospitalisation or isolation and
treatment at home
Home
Well informed consent
Guidelines to patient and household contact
Treatment to patient
Chemoprophylaxis to household contacts
Strict home quarantine
Children should not attend school
Not for passengers at the point of entry
68. CDC Guidelines for school
Inform students &parents about symptoms
Refer students with flu like symptoms
Use home isolation
Monitor closely
Consult with local authorities
70. Management of close contacts
Voluntary home quarantine x 7 days
Monitor for fever
Prompt testing and hospitalisation sos
when symptoms reported
All suspected cases need to be notified to
the state health authorities
71. Every day steps
Cover your nose & mouth
Wash your hands often with soap & water
Avoid touching your nose,mouth & eyes
Avoid close contact with sick people
If sick with flu like symptome stay home for at
least 24 hrs after fever is gone.
72. SOP for Infection control
Pre-Hospital Care
Three layer surgical mask for patient
Avoid aerosol generating procedure
Ambulance attendant – PPE
- N 95 mask
Ambulance driver - Three layer mask
Cleaning of ambulance interior by sodium
hypochlorite
Proper waste disposal
73. During Hospital care
Admit in isolation ward
Three layer mask for patient
Doctors , nurses , paramedical staff – PPE
- N-95 mask
Aerosol generating procedures with PPE and N95 mask
Hand hygiene
Cleaning of patient’s room, contaminated surface and
equipments daily by 5% Lysol / 10% sodium hypochlorite
Proper waste disposal
76. How to prevent disease spread ?
Home quarantine
Defer nonessential travel
Entry screening to all air ports / ports
Air port / port quarantine
Community quarantine
Social distancing measure –closure of school , college ,
cinema hall , market , shopping mall
Avoid mass gathering like festivals , marriage , sports ,
religious , political & funeral
77. Quarentine
If flu like symptomes stay home for 24 hrs
after symptomes have subsided
Confirmed case on temiflu isolate for 3 days
Confirmed case without drug isolate for 7
days
79. State Control Room
State Surveillance Unit
Directorate Health Services
Old Nurses Hostel , D.K.S. Mantralaya Campus,
Raipur
0771-2220011 ( 24 x 7 )